TABLE 3.
Postoperative care and biochemical monitoring
| Postoperative care and biochemical monitoring | Grade, evidence level, range of evidence |
|---|---|
| Recommendations | |
| •Specialist postoperative dietetic support should be provided including individualized nutritional supplementation, support and guidance to achieve long‐term weight loss and weight maintenance | Grade D EL 4 |
| •People who have bariatric surgery should have a postoperative follow‐up care package within the bariatric surgery service for a minimum of 2 years. This should include monitoring nutritional intake, dietary and nutritional assessment, advice and support | Grade D EL 4 |
| •People discharged from bariatric surgery service follow‐up should undergo monitoring of nutritional status at least once a year as part of a shared care model of management | Grade D EL 4 |
| Urea and electrolytes, renal and liver function tests | |
| •Monitor renal and liver function 3, 6 and 12 months in the first year and then at least annually | GPP |
| Haematinics | |
| Full blood count and ferritin | |
| •Check full blood count and serum ferritin at regular intervals post‐surgery | Grade B EL 2 (2+ to 2−) |
| •Consider the following frequency of monitoring of full blood count and ferritin levels: 3, 6 and 12 months in the first year and at least annually thereafter so that changes in status may be detected | GPP |
| Folate | |
| •Check serum folate levels at regular intervals post‐surgery | Grade B EL 2 (1+ to 2−) |
| •Consider the following frequency of monitoring of serum folate levels: 3, 6 and 12 months in the first year and at least annually thereafter so that changes in status may be detected | GPP |
| Vitamin B12 | |
| •Check vitamin B12 levels at regular intervals following SG, RYGB and malabsorptive procedures such as BPD/DS | Grade B EL 2 (2++ to 2−) |
| •Consider the following frequency of monitoring of vitamin B12 levels: 3, 6 and 12 months in the first year and at least annually thereafter so that changes in status may be detected | GPP |
| Vitamin D, calcium and parathyroid hormone | |
| Vitamin D | |
| •Check serum 25‐hydroxyvitamin D levels at regular intervals post‐surgery | Grade B EL 2 (1+ to 3) |
| •Serum 25‐hydroxyvitamin D levels of 75 nmol/L or greater are considered sufficient. | Grade D EL 4 |
| •Ensure total 25‐hydroxyvitamin D (D3 and D2) is measured if patient is on vitamin D2 supplements, e.g., ergocalciferol | GPP |
| •Consider the following frequency of monitoring of vitamin D levels: 3, 6 and 12 months in the first year and at least annually thereafter so that changes in status may be detected | GPP |
| Calcium | |
| •Check serum calcium levels at regular intervals | GPP |
| •Consider the following frequency of monitoring of serum calcium levels: 3, 6 and 12 months in the first year and at least annually thereafter so that changes in status may be detected | GPP |
| Parathyroid hormone | |
| •Check parathyroid hormone (to exclude primary hyperparathyroidism) if it has not been checked prior to surgery | GPP |
| Fat‐soluble vitamins A, E and K | |
| Vitamin A | |
| • Consider checking serum vitamin A levels if patient reports steatorrhoea or symptoms of vitamin A deficiency, for example, night blindness or protein malnutrition | Grade D EL 4 (2+ to 4) |
| •Check serum vitamin A levels at regular intervals following malabsorptive procedures such as BPD/DS | Grade B EL 2 (1+ to 2) |
| •Consider the following frequency of monitoring of serum vitamin A levels following malabsorptive procedures such as BPD/DS: every 3 months and then annually once levels are stable | GPP |
| Vitamin E | |
| •Check serum vitamin E levels at regular intervals following malabsorptive procedures such as BPD/DS | Grade B EL 2 (1+ to 2+) |
| •Consider monitoring of serum vitamin E levels at least annually following malabsorptive procedures such as BPD/DS | GPP |
| •Check serum vitamin E levels if unexplained anaemia or neuropathy | Grade D EL 4 |
| Vitamin K | |
| •Check vitamin K1 and PIVKA‐II levels at regular intervals following malabsorptive procedures such as BPD/DS | Grade B EL 2 (1+ to 3) |
| •Consider monitoring of serum vitamin K1 and PIVKA levels at least annually following malabsorptive procedures such as BPD/DS | GPP |
| Trace minerals: zinc, copper, selenium and magnesium | |
| Zinc | |
| •Check serum/plasma zinc levels at regular intervals following SG, RYGB or BPD/DS | Grade B EL 2 (1+ to 3) |
| •Consider monitoring serum/plasma zinc levels at least annually following SG, RYGB or BPD/DS | GPP |
| •Check serum/plasma zinc levels if unexplained anaemia, hair loss or changes in taste acuity | GPP |
| Copper | |
| •Check serum copper levels at regular intervals following SG, RYGB or BPD/DS | Grade C EL 3 (2− to 3) |
| •Consider monitoring serum copper levels at least annually following SG, RYGB or BPD/DS | GPP |
| • serum copper levels if unexplained anaemia or poor wound healing | GPP |
| •Serum copper should be monitored in patients taking zinc supplements and vice versa | GPP |
| Selenium | |
| •Check serum selenium levels if there is chronic diarrhoea, metabolic bone disease, unexplained anaemia or unexplained cardiomyopathy | Grade D EL 4 |
|
•Check serum selenium levels at regular intervals following RYGB •Check serum selenium levels at regular intervals following malabsorptive procedures such as BPD/DS •Consider monitoring serum selenium levels at least annually following RYGB or malabsorptive procedures such as BPD/DS |
Grade D EL 2 (2−) Grade C EL 2 (2+) GPP |
| Thiamine | |
| •If the patient presents with rapid weight loss, poor dietary intake, vomiting, alcohol abuse, oedema or symptoms of neuropathy, initiate treatment for thiamine deficiency immediately. Do not delay pending blood results | GPP |
| HbA1c, lipids | |
| •Monitor HbA1c in patients with preoperative diabetes | GPP |
| •Monitor lipids in patients with preoperative dyslipidaemia | GPP |
Abbreviations: AGB, adjustable gastric band; BPD/DS, duodenal switch; EL, evidence level and depicts where the majority of evidence lies; GPP, good practice point; PIVKA‐II, protein induced by vitamin K absence or antagonism; RYGB, Roux‐en‐Y gastric bypass, SG, sleeve gastrectomy.